ACL Rupture: Is Surgery Necessary?

Once your physiotherapist, or other trusted health professional, has diagnosed you with an anterior cruciate ligament (ACL) rupture, you might automatically think “Oh no - surgery!”

What if it doesn’t have to be that way?

Clinical trials looking into the best way to manage ACL rupture are continuing to support exercise therapy supervised by a physiotherapist, over surgery.

The participants in these studies are not people who sit at a desk every day either.

These are young, active people who play sports, including football and basketball.

Currently, the most common form of rehabilitation after an ACL rupture is a surgical reconstruction of the ACL followed by exercise therapy supervised by a physiotherapist.

It can take a couple of months to even get the surgery. Then it is up to a 12 month process to get you back to full function and sport. That's a long rehab, hey?!

What if you don’t need surgery? What if you can start your exercise therapy straight away?

You will be able to return to sport a lot quicker. Especially if you don’t have to wait for surgery, and if you don’t have to undergo the additional healing required when a graft taken from your own healthy tendon to be used to become your new ACL. (Yes, that's what they do - steal some of your own healthy tissue!)

Let’s look at the evidence.


The Evidence

The KANON trial, a high-quality randomized control trial (RCT), found no difference at 2 and 5 years following early reconstruction of the ACL plus exercise therapy compared to exercise therapy alone.

The study found there was no difference in muscle strength and physical performance in sport.

At 5 years after ACL rupture, the exercise therapy participants reported their knee to be an average 10-points better on the Knee Injury And Osteoarthritis Outcome Score (KOOS). Showing they had less pain, better knee function and better quality of life.

Osteoarthritis (OA) after ACL rupture is developed in around 50% of people. A study into the risk factors of OA post ACL rupture found quadriceps weakness to be a key factor, as well as body mass index and physical inactivity. This reinforces the importance of exercise therapy.

However, it is important to note that there are some knees that will not get back to full function without an ACL reconstruction.

There were participants in the KANON trial who commenced exercise therapy initially and with advice from their physiotherapist had a delayed ACL reconstruction. Some surgeries were done up to 56 months post ACL rupture.

The researchers believe that commencing exercise therapy first allows the acute signs of your injury to subside before considering surgery. It also allows a better development of strength and knee control.

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Take Away Message

The evidence for exercise therapy supervised by a physiotherapist is strong. It also doesn’t completely rule out surgery if it is applicable.

This blog is here to help to educate you on your options. It will allow you to have a discussion with your physiotherapist on the best way forward for your knee. I’ve linked a few references for some light reading.

Good luck for your recovery.



Frobell RB, Roos EM, Roos HP, et al. A Rabdomized Trial Of Treatment For Acute Anterior Cruciate Ligament Tears. N Engl J Med. (2010). 363:331-42.

Ericsson YB, Roos EM, Frobell RB. Lower Extremity Performance Following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years. British Journal of Sports Medicine. (2013) 47: 980-985.

Filbay SR, Roos EM, Frobell RB, Roemer F, Ranstam J, Lohmander LS. Delaying ACL Reconstruction And Treating With Exercise Therapy Alone May Alter Prognostic Factors For 5-Year Outcome: An Exploratory Analysis Of The KANON Trial. British Journal of Sports Medicine. (2017) 51 (22): 1622-1629.